{clni_form}
<table>
<tr>
<td>
Allergy:<br>
{input size="40" id="allergyText" name="allergy_name" type="string"}
<select onChange="document.getElementById('allergyText').value = this.options[this.selectedIndex].label;"><option>--Select allergy--</option> {enum_options name="allergies"} </select>
</td>
</tr>
<tr>
<td>
Date First Noted:<br>
{input name="allergy_date" type="date"}
</td>
</tr>
<tr>
<td>
Comments:<br>
{input size="50" name="comment" type="string"}
</td>
</tr>
<tr>
<td>
{submit}
</td>
</tr>
</table>
